Six Month Questionnaire

On the following pages are questions about activities children do. Your child may have already done some of the activities described here, and there may be some your child has not begun doing yet.
For each item, please check the box that tells whether your child is doing the activity regularly, sometimes, or not yet.

Important points to remember:

Be sure to try each activity with your child before checking a box.

Try to make completing this questionnaire a game that is fun for you and your child.

Make sure your child is rested, fed, and ready to play.

If you have any questions of concerns about your child or about this questionnaire, please call our office at (919) 460-0993.

Look forward to filling out another questionnaire in six months.

Child's Name:

Child's Date of Birth:

Child's corrected date of birth (if child is premature, add weeks of prematurity to the child's date of birth):

Today's Date:

Person filling out this questionnaire:

What is your relationship to the child?:

Your phone number:

Your mailing address:

City:
State:
Zip:

List of people assisting in the questionnaire completion:

Administering program or provider:

Communication

Be sure to try each activity with your child.

YES

SOMETIMES

NOT YET

1. Does your baby make high-pitched squeals?

2. When playing with sounds, does your baby make grunting, growling, or other deep-toned sounds?

3. If you call your baby when you are out of sight, does she look in the direction of your voice?

4. When a loud noise occurs, does your baby turn to see where the sound came from?

5. Does your baby make sounds like "da", "ga", "ka", and "ba"?

6. If you copy the sounds your baby makes, does your baby repeat the sounds back to you?

Communication Total:

Gross Motor

Be sure to try each activity with your child.

YES

SOMETIMES

NOT YET

1. While on his back, does your baby lift his legs high enough to see his feet?

2. When she is on her tummy, does your baby straighten both arms and push her whole chest off the bed or floor?

3. Does your baby roll from his back to his tummy, getting both arms out from under him?

4. When you put her on the floor, does your baby lean on her hands while sitting? (If she already sites up straight without leaning on her hands, check "yes" for this item.

5. If you hold both hands just to balance him, does your baby support his own weight while standing?

6. Does your baby get into a crawling position by getting up on her hand and knees?

Gross Motor Total:

Fine Motor

Be sure to try each activity with your child.

YES

SOMETIMES

NOT YET

1. Does your baby grab a toy you offer and look at it, wave it about, or chew on it for about 1 minute?

2. Does your baby reach for or grasp a toy using both hands at once?

3. Does your baby reach for a crumb or Cheerio and touch it with his finger? (If he already picks up a small object the size of a pea, then check "yes" for this item)

4. Does your baby pick up a small toy, holding it in the center of her hands with her fingers around it?

5. Does your baby try to pick up a crumb or Cheerio by using his thumb and all his fingers in a raking motion, even if he isn't able to pick it up? (If he already picks up the crumb or Cheerio, then check "yes" for this item)

6. Does your baby usually pick up a small toy with only one hand?

Fine Motor Total:

Problem Solving

Be sure to try each activity with your child.

YES

SOMETIMES

NOT YET

1. When a toy is in front of her, does your baby reach for it with both hands?

2. When he is on his back, does your baby turn his head to look for a toy when he drops it? (If he already picks it up, check "yes" for this item.)

3. When she is on her back, does your baby try to get a toy she has dropped if she can't see it?

4. Does your baby often pick up toys and put them in his mouth?

5. Does your baby pass a toy back and forth from one hand to the other?

6. Does your baby play by banging a toy up and down on the floor or table?

Problem Solving Total:

Personal-Social

Be sure to try each activity with your child.

YES

SOMETIMES

NOT YET

1. When in front of a large mirror, does your baby smile and coo at herself?

2. Does your baby act differently toward strangers then he does with you and other familiar people? (Reactions to strangers may include staring, frowning, withdrawing, or crying.)

3. While lying on her back, does your baby play by grabbing her foot?

4. When in front of a large mirror, does your baby reach out and pat the mirror?

5. While on his back, does your baby put his foot in his mouth?

6. Does your baby try to get a toy that is out of reach? (She may roll, pivot on her tummy, or crawl to get it.)

Personal-social Total:

Overall

Parents and providers may use the back of this sheet for additional comments.

1. Do you think your child hears well?

YES

NO

If no, explain:

2. Does your baby use both hands equally well?

YES

NO

If no, explain:

3. When you help your baby stand, are his feet flat on the surface most of the time?

YES

NO

If no, explain:

4. Does either parent have a family history of childhood deafness or hearing impairment?

YES

NO

If yes, explain:

5. Do you have concerns about your child's vision?

YES

NO

If yes, explain:

6. Has your child had any medical problems in the last several months?